=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194808998
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAE LYN BURKE PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 12/20/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 PARK STREET
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-873-6896
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 66 PARK STREET PO BOX 277
-----------------------------------------------------
City | ELIZABETHTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 12932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 518-873-6896
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 001251
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------